An international study on the use of peroral endoscopic myotomy in the management of Zenker's diverticulum.

BACKGROUND AND AIMS: The novel use of peroral endoscopic myotomy (POEM) in the treatment of Zenker's diverticulum (ZD) was recently described in case reports. The aim of this study is to report a multicenter experience with the POEM technique in the management of ZD. METHODS: This is a multicenter international retrospective study involving 10 centers. The Zenker's POEM technique was performed using principles of submucosal endoscopy. RESULTS: Seventy-five patients (73.3 ± 1.2 years, 33 women) were included with a mean Charleson comorbidity index of 4 ± .2. The mean size of ZD was 31.3 ± 1.6 mm (range, 10-89). The overall technical success rate was 97.3% (73/75). There were 2 technical failures because of the inability to locate the septum and failed tunnel creation. Adverse events occurred in 6.7% (5/75): 1 bleed (mild) conservatively managed and 4 perforations (1 severe, 3 moderate). The mean procedure time was 52.4 ± 2.9 minutes, and mean length of hospital stay was 1.8 ± .2 days. Clinical success was achieved in 92% (69/75) with a decrease in mean dysphagia score from 1.96 to .25 (P < .0001). The median length of follow-up was 291.5 days (interquartile range, 103.5-436). At the 12-month follow-up, 1 patient reported symptom recurrence. CONCLUSIONS: Endoscopic management of ZD using the POEM technique is novel and feasible with promising efficacy and safety results. Long-term follow-up is needed to ensure durability of response. In addition, comparative studies with other treatment modalities are warranted.

Experimental gastric endoscopic submucosal dissection: training in a porcine model.

BACKGROUND: Endoscopic submucosal dissection (ESD) requires special skills and a long procedure time for a quality-controlled procedure. A universal training system remains to be established. Hands-on courses in animal models before advancing to the human colon appear to be essential, especially in Europe. The learning curve is a prerequisite in ESD, in order to improve technical outcomes and decrease the rate of procedural adverse events. METHODS: In the experimental research center of ELPEN Pharmaceuticals, 18 European endoscopists, inexperienced at ESD, performed gastric ESDs in porcine models. The course lasted two days and was conducted under the supervision of experts. RESULTS: A total of 72 of 76 ESDs were completed en bloc (94.7%). The procedural time and cutting speed differed significantly between the first and second day: 48±4.4 vs. 43±4.8 min (P=0.0045), and 1.38±0.20 vs. 1.63±0.23 cm2/min (P=0.0033), respectively. The complications were not significantly different between the two groups: five (13.88%) vs. four (11%) episodes of bleeding (P>0.05). The perforation rate was similar, at two episodes per day (5.55%). We documented an acceptable rate of en bloc resections and complications. CONCLUSION: ESD demands a new level of endoscopic skills in Europe. A formal sequential training program, using porcine models, may benefit countries with a low volume of cases.

Updated terminology of chronic venous disorders: the VEIN-TERM transatlantic interdisciplinary consensus document.

Non-uniform terminology in the world's venous literature has continued to pose a significant hindrance to the dissemination of knowledge regarding the management of chronic venous disorders. This VEIN-TERM consensus document was developed by a transatlantic interdisciplinary faculty of experts under the auspices of the American Venous Forum (AVF), the European Venous Forum (EVF), the International Union of Phlebology (IUP), the American College of Phlebology (ACP), and the International Union of Angiology (IUA). It provides recommendations for fundamental venous terminology, focusing on terms that were identified as creating interpretive problems, with the intent of promoting the use of a common scientific language in the investigation and management of chronic venous disorders. The VEIN-TERM consensus document is intended to augment previous transatlantic/international interdisciplinary efforts in standardizing venous nomenclature which are referenced in this article.

Improving limb salvage in critical ischemia with intermittent pneumatic compression: a controlled study with 18-month follow-up.

BACKGROUND: Intermittent pneumatic compression (IPC) is an effective method of leg inflow enhancement and amelioration of claudication in patients with peripheral arterial disease. This study evaluated the clinical efficacy of IPC in patients with chronic critical limb ischemia, tissue loss, and nonhealing wounds of the foot after limited foot surgery (toe or transmetatarsal amputation) on whom additional arterial revascularization had been exhausted. METHODS: Performed in a community and multidisciplinary health care clinic (1998 through 2004), this retrospective study comprises 2 groups. Group 1 (IPC group) consisted of 24 consecutive patients, median age 70 years (interquartile range [IQR], 68.7-71.3) years, who received IPC for tissue loss and nonhealing amputation wounds of the foot attributable to critical limb ischemia in addition to wound care. Group 2 (control group) consisted of 24 consecutive patients, median age 69 years (IQR, 65.7-70.3 years), who received wound care for tissue loss and nonhealing amputation wounds of the foot due to critical limb ischemia, without use of IPC. Stringent exclusion criteria applied. Group allocation of patients depended solely on their willingness to undergo IPC therapy. Vascular assessment included determination of the resting ankle-brachial pressure index, transcutaneous oximetry (TcPO(2)), duplex graft surveillance, and foot radiography. Outcome was considered favorable if complete healing and limb salvage occurred, and adverse if the patient had to undergo a below knee amputation subsequent to failure of wound healing. Follow-up was 18 months. Wound care consisted of weekly débridement and biologic dressings. IPC was delivered at an inflation pressure of 85 to 95 mm Hg, applied for 2 seconds with rapid rise (0.2 seconds), 3 cycles per minute; three 2-hourly sessions per day were requested. Compliance was closely monitored. RESULTS: Baseline differences in demography, cardiovascular risk factors (diabetes mellitus, smoking, hypertension, dyslipidemia, renal impairment), and severity of peripheral arterial disease (ankle-brachial indices, TcPO(2), prior arterial reconstruction) were not significant. The types of local foot amputation that occurred in the two groups were not significantly different. In the control group, foot wounds failed to heal in 20 patients (83%) and they underwent a below knee amputation; the remaining four (17%, 95% confidence interval [CI], 0.59%-32.7%) had complete healing and limb salvage. In the IPC group, 14 patients (58%, 95% CI, 37.1%-79.6%) had complete foot wound healing and limb salvage, and 10 (42%) underwent below knee amputation for nonhealing foot wounds. Wound healing and limb salvage were significantly better in the IPC group (P < .01, chi(2)). Compared with the IPC group, the odds ratio of limb loss in the control group was 7.0. On study completion, TcPO(2) on sitting was higher in the IPC group than in the control group (P = .0038). CONCLUSION: IPC used as an adjunct to wound care in patients with chronic critical limb ischemia and nonhealing amputation wounds/tissue loss improves the likelihood of wound healing and limb salvage when established treatment alternatives in current practice are lacking. This controlled study adds to the momentum of IPC clinical efficacy in critical limb ischemia set by previously published case series, compelling the pursuit of large scale multicentric level 1 studies to substantiate its actual clinical role, relative indications, and to enhance our insight into the pertinent physiologic mechanisms.

Median arcuate ligament syndrome: open celiac artery reconstruction and ligament division after endovascular failure.

Median arcuate ligament syndrome (MALS) is a rare disorder resulting from extrinsic compression and narrowing of the celiac artery, and--less often--the superior mesenteric artery, by the relatively low insertion of the ligament and/or prominent fibrous bands or ganglionic periaortic tissue of the celiac nervous plexus. We report on a young woman who after three consecutive attempts of endovascular therapy with balloon angioplasty and stenting for MALS, each followed by gross symptom recurrence and a cumulative weight loss of 10 kg, underwent open surgical division of the ligament and reconstruction of the celiac artery. Despite the initial response of MALS to endovascular therapy, the extrinsic pressure exerted on the celiac artery by the surrounding dense fibrous/ganglionic tissue resulted in slippage of the stents and/or failure of their material. These findings militate against the use of balloon angioplasty and stenting primarily in patients with MALS without prior release of the extrinsic compression on the celiac (and/or superior mesenteric) artery by dividing the surrounding median arcuate ligament and/or ganglionic tissue with open or laparoscopic surgery.

Hemodynamic impairment, venous segmental disease, and clinical severity scoring in limbs with Klippel-Trenaunay syndrome.

BACKGROUND: Klippel-Trenaunay syndrome (KTS) is a complex congenital anomaly featuring two or more of the following: (1) capillary malformations (port-wine stains), (2) soft tissue or bony hypertrophy (or both), and (3) varicose veins or venous malformations. With the purpose of determining the actual significance of venous impairment in patients with KTS, we quantified the venous valvular competency and calf muscle pump function and examined their effect on clinical severity. METHODS: Included were patients with near-normal function of affected limb(s) and minimal/small foot hypertrophy. Excluded were those with deep venous hypoplasia, aplasia or thrombosis, lymphedema, limb length discrepancy (>2.5 cm), peripheral arterial (ankle-brachial index <1.0), or cardiac disease and walking impairment. Venous duplex scanning, ascending venography, magnetic resonance imaging, strain gauge plethysmography, and a bone scanogram were performed. We studied eight men and seven women aged 15 to 51 years (median, 24 years). The KTS involved 17 limbs (unilateral in 13 patients and bilateral in 2). Contralateral limbs in patients with unilateral KTS acted as controls (n = 13). Venous clinical severity was graded according to the CEAP and venous clinical severity score (VCSS), and reflux complexity was classified according to the venous segmental disease score. Outflow obstruction (outflow fraction at 1 and 4 seconds; OF(1) and OF(4), respectively), reflux (venous filling index), calf muscle pump function (ejection fraction), and hypertension (residual volume fraction) were determined in both limbs with strain gauge plethysmography. Data, reported as median and interquartile range, were analyzed with the Mann-Whitney test. RESULTS: Varicose veins or venous malformations occurred in the medial, posterior, or anterolateral limb segments of the ankle (7/17, 7/17, and 9/17), calf (10/17, 8/17, and 12/17), knee (9/17, 8/17, and 8/17), and thigh (10/17, 6/17, and 8/17, respectively). Venous malformations occupied the subcutaneous space (17/17) and extended into the subfascial space in 6 (35.3%) of 17 limbs. Abnormal reflux (>0.5 seconds) was distributed in the great (64.7%; 11/17) and small (5.9%; 1/17) saphenous veins and the common femoral (23.5%; 4/17), femoral (41.1%; 7/17), popliteal (29.4%; 5/17), perforator (70.6%; 12/17), and axial calf (35.3%; 6/17) veins. There was no difference in the OF(1) and OF(4) between the affected limbs and the controls. Limbs with KTS had a fivefold greater venous filling index (0.133-0.46 mL . 100 mL(-1) . s(-1); 0.258 mL . 100 mL(-1) . s(-1)) than the controls (0.034-0.055 mL . 100 mL(-1) . s(-1); 0.046 mL . 100 mL(-1) . s(-1); P < .0001), and this was linked to a higher venous segmental disease score (3 [2-4] vs 0 [0-1]; P < .0001). Limbs with KTS had half the ejection fraction (20.8%; 12.3%-24%) of the controls (39.3%; 30.9%-64.6%) and twice as high a residual venous fraction (77% [69.6%-84.5%] vs 40.9% [20.6%-60%]; both P < .004). Patients complained of swelling (100%; 15/15), aching (100%; 15/15), pain (93.3%; 14/15) and heaviness (100%; 15/15), tiredness (66.7%; 10/15), and tightness (33.3%; 5/15) of the limb(s) with KTS. Limbs with KTS had a worse (1) venous clinical severity by 11 VCSS points (11 [8-12] vs 0 [0-1]) and (2) clinical status by 3 CEAP classes (C3 [C3-C4] vs C0 [C0-C2]) than the control limbs (both P < .0001). CONCLUSIONS: Venous disease in limbs with KTS is a major source of morbidity in affected patients. Limbs with KTS are characterized by complex reflux patterns, severe valvular incompetence, calf muscle pump impairment, and venous hypertension, thus explaining the advanced clinical severity (VCSS) and CEAP grade.

Successful iliac vein and inferior vena cava stenting ameliorates venous claudication and improves venous outflow, calf muscle pump function, and clinical status in post-thrombotic syndrome.

OBJECTIVES: Stent therapy has been proposed as an effective treatment of chronic iliofemoral (I-F) and inferior vena cava (IVC) thrombosis. The purpose of this study was to determine the effects of technically successful stenting in consecutive patients with advanced CVD (CEAP3-6 +/- venous claudication) for chronic obliteration of the I-F (+/-IVC) trunks, on the venous hemodynamics of the limb, the walking capacity, and the clinical status of CVD. These patients had previously failed to improve with conservative treatment entailing compression and/or wound care for at least 12 months. METHODS: The presence of venous claudication was assessed by > or =3 independent examiners. The CEAP clinical classification was used to determine the severity of CVD. Outflow obstruction [Outflow Fraction at 1- and 4-second (OF1 and OF4) in %], venous reflux [Venous Filling Index (VFI) in mL/100 mL/s], calf muscle pump function [Ejection Fraction (EF) in %] and hypertension [Residual Venous Fraction (RVF) in %], were examined before and after successful venous stenting in 16 patients (23 limbs), 6 females, 10 males, median age 42 years; range, 31-77 yearas, left/right limbs 14/9, using strain gauge plethysmography; 7/16 of these had thrombosis extending to the IVC. Contralateral limbs to those stented without prior I-F +/- IVC thrombosis, nor infrainguinal clots on duplex, were used as control limbs (n = 9). Excluded were patients with stent occlusion or stenoses, peripheral arterial disease (ABI <1.0), symptomatic cardiac disease, unrelated causes of walking impairment, and malignancy. Preinterventional data (< or =30 days) were compared with those after endovascular therapy (8.4 months; interquartile range [IQR], 3-11.8 months). Nonparametric analysis was applied. RESULTS: Compared with the control group, limbs with I-F +/- IVC thrombosis before stenting had reduced venous outflow (OF4) and calf muscle pump function (EF), worse CEAP clinical class, and increased RVF (all, P < 0.05). At 8.4 months (IQR, 3-11.8 months) after successful I-F (+/-IVC) stenting, venous outflow (OF1, OF4) and calf muscle pump function (EF) had both improved (P < 0.001) and the RVF had decreased (P < 0.001), at the expense of venous reflux, which had increased further (increase of median VFI by 24%; P = 0.002); the CEAP status had also improved (P < 0.05) from a median class C3 (range, C3-C6; IQR, C3-C5) [distribution, C6: 6; C4: 4; C3: 13] before intervention to C2 (range, C2-C6; IQR, C2-C4.5) [distribution, C6: 1; C5: 5; C4: 4; C2: 13] after intervention. At this follow up (8.4 months median), venous outflow (OF1, OF4), calf muscle pump function (EF), and RVF of the stented limbs did not differ significantly from those of the control; significantly worse (P < 0.025) were the amount of venous reflux (VFI), and the CEAP clinical class, despite the improvement with stenting. Incapacitating venous claudication noted in 62.5% (10 of 16, 95% CI, 35.8%-89.1%) of patients (15 of 23 limbs; 65.2%, 95% CI, 44.2%-86.3%) before stenting was eliminated in all after stenting (P < 0.001). CONCLUSIONS: Successful I-F (+/-IVC) stenting in limbs with venous outflow obstruction and complicated CVD (C3-C6) ameliorates venous claudication, normalizes outflow, and enhances calf muscle pump function, compounded by a significant clinical improvement of CVD. The significant increase in the amount of venous reflux of the stented limbs indicates that elastic or inelastic compression support of the successfully stented limbs would be pivotal in preventing disease progression.

Neurofibromatosis type 1: from presentation and diagnosis to vascular and endovascular therapy.

Neurofibromatosis type 1, also called von Recklinghausen's disease, is an autosomal dominant disorder linked to chromosome 17, characterized by growth impairment of the neural crest cells (ectoderm) manifested by multiple neural tumors, cutaneous pigmentations, and Lisch nodules. Disease phenotype develops with time, making its penetrance almost complete by 5 years of age. Compression of the gastro-intestinal, urinary, or pulmonary tracts by visceral neurofibromas may generate serious complications. Neurofibromatosis type 1 is remarkable for its association with occlusive (stenoses) or aneurysmal arterial disease affecting predominantly the renal arteries and less often the abdominal aorta (middle aortic syndrome), and mesenteric and peripheral arteries. Appraisal of existing literature reveals that timely vascular intervention by way of conventional surgery and/or endovascular therapy may provide patients with effective and durable treatment. The far greater propensity for malignant connective/soft-tissue neoplasms and vascular disease in neurofibromatosis type 1, amid potential complications from the gastro-intestinal, urinary, and pulmonary tracts, leads to a significantly increased morbidity and decreased life expectancy. Neurofibromatosis type 1, from presentation and diagnosis to its treatment, is reviewed, with emphasis on vascular disease and its management with open vascular surgery and endovascular therapy.

The nonsaphenous vein of the popliteal fossa: prevalence, patterns of reflux, hemodynamic quantification, and clinical significance.

BACKGROUND: A large tortuous vein coursing over the posterior aspect of the knee and the upper calf may give rise to a constellation of varicose veins unrelated to the great (GSV) or small (SSV) saphenous veins. Designated the popliteal fossa vein (PFV), it perforates the deep popliteal fascia and empties into the deep system. We examined the prevalence, anatomic reflux patterns, hemodynamic role, and clinical significance of the PFV. METHODS: We examined 543 patients (818 limbs) with venous disease, aged 14 to 94 years (median, 55 years). The study consisted of group A, comprising limbs with a PFV, and group B, formed by the remaining limbs. The history, clinical examination, and venous duplex scan findings were analyzed retrospectively. Venous clinical severity and venous segmental disease scores of group A were compared with those of an equal number of CEAP-, sex-, and age-matched control limbs. In situ venous hemodynamics of the PFV obtained with duplex scan are reported. RESULTS: A PFV was found in 24 (2.93%) of 818 limbs (95% confidence interval [CI], 1.8%-4.1%); 24 (4.4%) of 543 subjects (95% CI, 2.7%-6.2%), 12 men and 12 women aged 23 to 82 years (median, 54 years) had a PFV. CEAP clinical classes in limbs with a PFV were as follows: C2, 15 limbs; C3, 5 limbs; C4, 2 limbs; C5, 1 limb; and C6, 1 limb. Proximal and distal (92%), superficial (100%), perforator (87.5%), and complex-pattern (41.7%) reflux occurred more often in group A (P < .01). Incompetence in the GSV (75%), posterior arch, and posteromedial and saphenous tributaries was also more frequent in group A (P < .05). SSV reflux in group A (29%) matched that in group B. The PFV terminated at the deep system (96% in the popliteal vein) above the SSV (median distance, 1.5 cm; 95% CI, 0.5-2 cm). The odds ratio for a PFV in limbs with prior SSV disconnection was 5.68. Deep reflux was evenly distributed in group A (41.7%) and group B (27%). The prevalence of incompetent perforators was 283% (95% CI, 194%-373%) in group A and 96% (95% CI, 95%-98%) in group B (P < .001). PFV tributaries were distributed at the popliteal area (100%); the posterior (87.5%), medial (62.5%), and lateral (37.5%) upper calf; and the posterior distal thigh (17%), often projecting to the posterior GSV arch (50%). The (median) peak velocity of reflux in the PFV was 82.6 cm/s, the mean velocity was 17.7 cm/s, the duration was 2.4 seconds, the volume flow was 231.5 mL/min, and the expelled volume was 9.3 mL. The median diameter of the PFV at the crossing of the fascia was 0.527 cm. Venous clinical severity (range, 2-17; median, 5.5) and venous segmental disease (range, 0.5-8; median, 2.75) scores in limbs with a PFV exceeded (P

Endovascular repair of ruptured saccular aneurysms of the descending thoracic aorta.

Open repair of ruptured aneurysms of the descending thoracic aorta (DTA) is associated with early mortality rates of 20%-60% and severe morbidity rates exceeding 40%. The present report describes three octogenarian patients and one sexagenarian patient at poor surgical risk admitted with acutely ruptured saccular DTA aneurysms (two of four were anastomotic) unrelated to trauma or infection who underwent successful endovascular therapy, which involved the use of aortic endovascular cuffs in three cases. Mean intensive care unit and total hospital stay durations were 1.75 days (range, 1-4 d) and 6 days (range, 3-13 d), respectively. At 30 days, all patients were alive and free of repeat intervention, with aneurysm exclusion achieved in all cases but one, which featured a marginal type II endoleak. These data support endovascular therapy for ruptured saccular DTA aneurysms enabling short-term outcomes that otherwise would have been unrealistic.

Aortic fenestration for chronic aortic dissection type B complicated by transient ischemic attacks of spinal cord.

Spinal cord injury is a rare complication in patients with aortic dissection. The extrinsic arterial supply to the spinal cord, diminishing caudally, often becomes critically dependent on the great radicular artery (GRA) of Adamkiewicz at the thoracolumbar spine. There are no prior reports of spinal injury or ischemia caused by chronic aortic dissection. We report on a 51-year-old patient with chronic type B dissection of the aorta from below the subclavian takeoff through the iliac arteries, presented with multiple episodes of transient (1 to 5 minutes) spinal ischemic attacks, entailing sudden loss of motor and sensory functions in both legs, with collapse of the patient on the ground. GRA imaging acquired with 64-channel computed tomography angiography enabled aortic fenestration from T11 to L1, performed with supraceliac aortic cross-clamping (T8 to L2) via thoracoabdominal access. We critically appraise the pertinent literature.

Middle aortic syndrome: from presentation to contemporary open surgical and endovascular treatment.

Middle aortic syndrome (MAS) is a clinical condition generated by segmental narrowing of the abdominal or distal descending thoracic aorta. MAS may be acquired, caused by Takayasu's or temporal arteritis (giant cell arteritides), neurofibromatosis, fibromuscular dysplasia, retroperitoneal fibrosis, mucopolysaccharidosis, and the Williams syndrome, or congenital, ascribed to a developmental anomaly in the fusion and maturation of the paired embryonic dorsal aortas. Segmental aortic stenosis may be located at the suprarenal, inter-renal or infrarenal aorta, with a high propensity for concomitant stenoses in both the renal (63%) and visceral (33%) arteries. Hypertension proximal to the aortic stenosis, and relative hypotension distal to it, are characteristic findings in MAS. Typical manifestations include headache, early fatigue on exertion, and bilateral lower-limb claudication. The severity of hypertension is the primary indication for intervention and the factor determining procedural timing. As a great proportion of patients with MAS are children or teenagers, the clinical benefits of early surgical intervention to reverse refractory hypertension have to be weighed against the repercussions pertaining to the insult of surgery on the developing aorta. Open surgery is the primary treatment of tubular aortic narrowing (MAS) associated with renovascular hypertension and visceral artery stenosis. This entails aortoaortic bypass of the diseased segment or, less often, patch aortoplasty and usually bypass grafting of the stenosed renal and visceral arteries performed with autologous conduits, particularly in the youngest of patients. Endovascular therapy may provide a sound minimally invasive treatment in MAS caused by discrete aortic stenoses that do not encompass the mesenteric and renal arteries. Hypertension is thus improved or cured in more than 70% of patients. Prognosis after uncompromised surgical reconstruction is rewarding in the mid and long term in patients with congenital aortic coarctation but deteriorates in patients with aortoarteritis and recurrent inflammatory activity.

Duration and amplitude decay of acute arterial leg inflow enhancement with intermittent pneumatic leg compression: an insight into the implicated physiologic mechanisms.

PURPOSE: By acutely enhancing the arterial leg inflow, intermittent pneumatic leg compression (IPC) improves the walking ability, arterial hemodynamics, and quality of life of claudicants. We quantified the duration of acute leg inflow enhancement with IPC of the foot (IPC(foot)), calf (IPC(calf)), or both (IPC(foot+calf)) and its amplitude decay in claudicants and controls in relation to the pulsatility index, an estimate of peripheral resistance. These findings are cross-correlated with the features of the three implicated physiologic mechanisms: (1) an increase in the arteriovenous pressure gradient, (2) suspension of peripheral sympathetic autoregulation, and (3) enhanced release of nitric oxide with flow and shear-stress increase. METHODS: Twenty-six limbs of 24 claudicants with superficial femoral artery occlusion or stenoses (>75%) and 24 limbs of 20 healthy controls matched for age and sex, meeting stringent selection criteria, had their popliteal volume flow and pulsating index (peak-to-peak velocity/mean velocity) measured with duplex scanning at rest and upon delivery of IPC. Spectral waveforms were analyzed for 50 seconds after IPC delivery per 5-second segments. The three IPC modes were applied in a true crossover design. Data analysis was performed with the Page, Friedman, Wilcoxon, Mann-Whitney and chi2 tests. RESULTS: The median duration of flow enhancement in claudicants exceeded 50 seconds with IPC(foot), IPC(calf), and IPC(foot+calf) but was shorter (P < .001) in the controls (32.5 to 40 seconds). Among the three IPC modes, the duration of flow enhancement differed (P < .05) only between IPC(foot) and IPC(foot+calf). After reaching its peak within 5 seconds of IPC, flow enhancement decayed at rates decreasing over time (trend, P < .05, Page test), which in both groups were highest at 5 to 20 seconds, moderate at 20 to 35 seconds, and lowest at 35 to 50 seconds (P < .05, Friedman test). Baseline and peak flow with all IPC modes was similar between the two groups. Pulsatility index attenuation in claudicating limbs lasted a median 32.5 seconds with IPC(foot), 37.5 seconds with IPC(calf), and 40 seconds with IPC(foot+calf); duration of pulsatility index attenuation was shorter in the control limbs with IPC(foot) (30 seconds), IPC(calf) (32.5 seconds), or IPC(foot+calf) (35 seconds), yet differences, as well as those among the 3 IPC modes, were not significant. CONCLUSION: Leg inflow enhancement with IPC exceeds 50 seconds in claudicants and lasts 32.5 to 40 seconds in the controls. Peak flow occurs concurrently with maximal pulsatility index attenuation, within 5 seconds of IPC. Irrespective of group or IPC mode, the decay rate (%) of flow enhancement is highest within 5 to 20 seconds of IPC, moderate at 20 to 35 seconds, and lowest at 35 to 50 seconds. Since attenuation in peripheral resistance terminates with the mid time period (20 to 35 seconds) of flow decay, and nitric oxide has a half-life of <7 to 10 seconds, the study's data indicate that all implicated physiologic mechanisms (1, 2, and 3) are likely active immediately after IPC delivery (0 to 20 sec) and all but nitric oxide are effective in the mid time period (20 to 35 seconds). As the pulsatility index has returned to baseline, the late phase of flow enhancement (35 to 50 seconds) could be attributable to the declining arteriovenous pressure gradient alone.

Large symptomatic carotid body tumor resection aided by preoperative embolization and mandibular subluxation.

Carotid body tumors (CBT) are rare and usually benign neoplasms (60%-90%), originating from the mesoderm and neural ectoderm. In view of the extensive and unrelenting growth of unresected CBT, encasing vital neurovascular structures, and the significant incidence of malignancy (> or = 10%), surgical excision is the standard treatment of choice. Despite progress in CBT imaging and surgical technique, cranial nerve deficit, stroke, and death continue to affect 10% to 40% of patients undergoing curative surgical resection, particularly in large tumors proximal to the skull base. In such cases, CBT shrinkage by preoperative embolization, improved surgical access utilizing mandibular subluxation, and electroencephalographic monitoring combined with meticulous surgical technique may enable curative tumor resection, without prohibitive morbidity. In light of associated disability, preoperative acknowledgment of the ever-present substantial risk of cranial nerve injury cannot be overemphasized. We report on a patient with a large symptomatic CBT treated surgically with the aid of mandibular subluxation and preoperative embolization.

The case for intermittent pneumatic compression of the lower extremity as a novel treatment in arterial claudication.

Appreciation of the physiologic role of the natural muscle pumps of the lower limb in enhancing the return of venous blood promoted the development of intermittent pneumatic limb compression (IPC) systems that could activate these pumps artificially. The application of IPC to the foot (IPC(foot)), calf (IPC(calf)) or both (IPC(foot + calf)) on dependency generates a significant acute arterial leg inflow enhancement in patients with intermittent claudication that is highest with IPC(foot + calf), followed by IPC(calf) and IPC(foot). This enhancement is attributable to the leg venous pressure decrease after venous expulsion with IPC, which results in arteriovenous pressure elevation, and a marked attenuation in peripheral resistance to flow due to a transient abolition of peripheral sympathetic autoregulation and the release of nitric oxide. Implementation of IPC(foot) and IPC(foot + calf) for 3 to 5 months (> or = 2.5 hours/day) has been shown to improve the walking capacity and the ankle pressure indices of patients with intermittent claudication, with a significant beneficial impact on the quality of life. As the prevalence of symptomatic peripheral arterial disease is projected to increase substantially over the next decades with the aging population in Western societies and in the absence of established, cost-effective methods of treatment for claudication, the reported efficacy of IPC in claudication certainly warrants clinical attention. Level-1 clinical evidence by three independent investigators supports the clinical role of IPC in arterial claudication, reinforced by its domiciliary applicability, the high patient compliance with which it is associated, and the modest cost. This review offers an insight into the hemodynamic and clinical effects of IPC in patients with claudication in relation to the physiologic mechanisms proposed in explanation of these effects.